[Mckittrick-Wheelock syndrome as a rare manifestation of villous adenoma of the rectum]

McKittrick-Wheelock syndrome is a rare disease when villous adenoma of the distal colon predisposes to profuse watery diarrhea with subsequent severe electrolyte disturbances and acute renal damage. A differentiated approach to correct diagnosis requires in-depth pathophysiological knowledge of regulation of water-electrolyte metabolism, functional and organic disorders of gastrointestinal tract and clinical manifestations of hypoosmolar dehydration. The peculiarity of the McKittrick-Wheelock syndrome is a 100% probability of death without treatment and complete regression of symptoms under complex correction of homeostasis and total resection of tumor. We demonstrate the main clinical trends of the McKittrick-Wheelock syndrome. This report may be useful for general practitioners, gastroenterologists, oncologists, nephrologists and anesthesiologists.

[Oral nutrition supplements: applied classification of formulas and basic rules of their prescribing in oncology]

The analysis of current data concerning the use of oral nutrition supplements (ONS) in cancer patients has been performed. The aim of the research is improving the effectiveness of medical nutrition in cancer patients by clarifying terms, definitions, developing an applied classification of ONS formulas and outlining the basic approaches for their use.

MATERIAL AND METHODS

Using the keywords «cancer», «oral nutritional supplements», and «siping», the literature was searched in such databases as eLIBRARY (elibrary.ru) and MEDLINE (ncbi.nlm.nih.gov) in Russian and English.

RESULTS AND DISCUSSION

The definition of this type of nutritional support has been given. The applied classification of ONS formulas has been made. Depending on the energy and protein content, presence of some specific nutrients, osmolarity, nitrogen/non-protein kilocalories ratio and viscosity, they were divided into 3 groups. For the initial assessment of nutritional status of the cancer patient, the European society for medical oncology scale (ESMO, 2008) is the most appropriate. Emphasis is placed on the importance of maintaining physical activity.

CONCLUSION

An approximate algorithm of ONS prescribing in oncology has been formulated.

[Regional and peripheral blockades for prevention of chronic post-thoracotomy pain syndrome in oncosurgical practice]

AIM

To compare an effectiveness of thoracic epidural anesthesia/analgesia, paravertebral and intercostal blockades in prevention of chronic post-thoracotomy pain syndrome (CPTPS) in oncosurgery.

MATERIAL AND METHODS

There were 300 patients who underwent open surgery including lobectomy or pneumonectomy. Patients were randomized into 3 groups depending on type of anesthesia: TEA (n=100) - combined general and epidural anesthesia; PVB (n=50) - combined general and paravertebral anesthesia; ICB (n=50) - general anesthesia was supplemented by intercostal blockade after removal of the drug.

RESULTS

CPTPS incidence was 34 and 40% in 6 months postoperatively after PVB and ICB, respectively (p>0.05). In TEA group this value was significantly lower compared with ICB group (23%, p<0.05).

CONCLUSION

TEA contributes to significant reduction of CPTPS incidence, while paravertebral blockade does not affect the frequency of this complication.

[Background and perspectives of opioid analgesics for the treatment of chronic pain in cancer patients in Russia]

The article deals with an analysis of availability of narcotic analgesics for the patients in the Russian Federation. The analysis was based on datafrom official sources on the scopes of opioids delivery in different regions of the Russian Federation and showed an extremely limited availability of narcotic analgesics for the patients in the Russian Federation. We found that availability of narcotic analgesics in Russia is hundreds times lower than the same indexes in European countries with various level of economic activity and in the USA. The analysis showed ten most progressive Russian regions where the use of opioids in the noninvasive forms has become part of systematic clinical practice according to WHO recommendations as well as 10 ten most backward regions where these drugs are hardly used despite of high figures of case death rates from cancer. We made a list of most needed modern Russian and internationally produced drugs according to international data and personal experience. Drugs from this list can be effectually used for the chronic pain therapy in oncology. The most advanced drugs that are soon will be produced are also named. The article describes high priority measures that have already been done to improve current situation and measures to be executed in the future.

[Anaesthesia and intensive care during intraoperative intraperitoneal hyperthermic chemotherapy in patients with gastric cancer (literature review and own clinical experience)]

Despite a steady decline in the incidence in recent decades, gastric cancer remains one of the most frequent causes of death from cancer in the world. By the time of diagnosis the tumor process is locally advanced or generalized in nearly 70% of patients that reduces the possibility of radical surgical treatment. Peritoneal carcinomatosis is a one of the main causes of treatment failure. There patients need complex treatment with cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy (IHIC) to improve the quality and duration of life. Today in Russia, surgeries with IHIC are performed in a very limited number of oncology hospitals, thus there is no unified approach to the perioperative management of these patients.

DESIGN

Since November 2010 in our institution we started a prospective clinical study of the use of intraoperative hyperthermic intraperitoneal chemotherapy in patients with locally advanced or metastatic gastric cancer.

MATERIALS AND METHODS

The study included 30 patients (18 men and 12 women) who underwent transabdominal gastrectomy with extended lymphadenectomy D2, supplemented principled cholecystectomy and oophorectomy (in women). Mean age was 48.5 ± 5.3 years. Technique involved the use of regional anesthesia com- ponent and inhalation anesthetic sevoflurane. Preoperative preparation included enteral nutrition (based on 25-30 kcal/ kg/day), liver protection (intravenous remaxol infusion of 500 ml/day for 3 days prior to surgery), antisecretory and antifermental therapy (omeprazole 40 mg/day, 100 mg octreotide for 2 h before surgey, aprotinin sulfate 30000 after induction of anesthesia), antioxidant and immunomodulatory therapy (galavit, cytoflavin, ceruloplasmin vitamin C), anticoagulant prophylaxis (enoxaparin sodium 40 mg on the evening before surgery).

RESULTS

Analysis of the world and our own clinical experience with intraoperative hyperthermic intraperitoneal chemotherapy in a comprehensive plan of treatment of patients with gastric cancer showed that the this aggressive, but highly effective technique can be requires not only careful patient selection according to the criteria, but also the use of special methods to protective therapy at all stages of the surgical treatment. Application of pathogenetic ways of protection from thermal injury, timely control and correction of homeostasis caused by the toxic effects of chemotherapy and burn peritoneum, early enteral nutrition and the use of organ-therapy reduce the risk of complications and achieve better results of treatment in cancer patients.

[Role of migraine history in the development of postoperative nausea and vomiting in patients undergoing general and combined general-epidural anesthesia]

PURPOSE OF THE STUDY

To assess the role of migraine history in the development of postoperative nausea and vomiting (PONV) in patients undergoing general and combined general-epidural anaesthesia.

MATERIALS AND METHODS

127 women with oncogynecological pathology were randomized into 3 groups according to anaesthesia method. Patients of the group C (comparative group; n = 43; 18 with migraine) received general anaesthesia. Patients of the Group CA (n = 40; 19 with migraine) received combined general-epidural anaesthesia. Patients of the group D (n = 44; 19 with migraine) received general anaesthesia with adding of Droperidolum. All patients received standard prophylactics of PONV- Ondansetronum 8 mg and dexamethasone 8 mg intravenous.

RESULTS

In the group C a PONV occurred in 15 of 43 women (34.9%). PONV occurred in 6 of 18 women with migraine (33.3%) and in 9 of 25 women without migraine (36%). In the group CA a PONV occurred in 10 of 40 women (25%). PONV occurred in 8 of 19 women with migraine (42.1%) and in 2 of 21 women without migraine (9.5%; p = 0.036 in comparison with group C). In the group D a PONV occurred in 8 of 44 women (18.2%). PONV occurred in 1 of 19 women with migraine (5.3% p = 0.03 in comparison with group C and p = 0.008 with group CA) and in 7 of 25 women without migraine (28%; there was no significant difference with groups C and CA).

CONCLUSIONS

Migraine history is a significant risk factor of PONV. Epidural component of anaesthesia does not effect on frequency of PONV in women with migraine, but Droperidolum use allows increasing the frequency of PONV.

[The problem of perioperative care of patients with high risk of heart arrhythmias in oncosurgery]

This review is devoted to analysis of the world experience of perioperative care in patients with high risk of development and aggravation of heart rhythm and conduction disturbances. There was given the definition of the arrhythmia, their modern classification, described the mechanisms of formation and causes of long duration. Special attention is paid to the problem of perioperative arrhythmias in oncosurgery, which is characterized by the extent and traumatic interventions in reflexogenic zones in patients with nutritive deficiency, hypovolaemia, anemia, electrolyte imbalance. The problem of interaction of antiarrhythmic drugs with anaesthetics, possible complications and ways of correction of hemodynamically significant bradycardia with the help of drugs (atropine, sympathomimetics) and drug-free (transesophageal (TEECS) and invasive cardiac stimulation) methods. Describes approaches to the diagnosis and prediction of the risk of the arrhythmia development with the help of the analysis of Holter ECG results with e of heart rhythm variability (HRV) assessment.

[The algorith of preoperative cardiovascular therapy in high risk elderly oncology patients]

The study was based on 478 oncology patients (72.1 +/- 3.6 years old) with cardiovascular comorbidities operated from 1991 to 2008 in regards of abdominal and pelvic mainly 3rd stage tumors with multimodal general anesthesia (4.2 +/- 1.6 hours). In prospective group (n = 302) all patients received cardiovascular treatment, while in retrospective group (n = 176) only 48.9% received it. The evaluation of the cardiovascular therapy effect was based on the peri-operative and postoperative HR and BP dynamics. The occurrance of noticeable bradycardia and drop of BP lower than 90/60 mm Hg was considered as a deviation. It is revealed that the cardiovascular therapy with beta adrenoblockers and calcium antagonists leads to an intraoperative bradycardia in 59.8% and 73.7% of cases, while in patients without the aforementioned therapy in 26.6% and 46.4% of cases respectively (p < 0.05). Antiarrhythmics don't have a noticeable impact on the development of bradycardia (p = 0.204). Intraoperative hypotension on the basis of ATP inhibitor treatment developed in 92.2% of patients statistically significant (p < 0.01). Monotherapy with calcium antagonists or nitrates leads to the development of hypotension in 55.2% and 41.4% of cases respectively, though in patients without the given therapy a lot more often (p < 0.05). In the case of combined calcium antagonist/nitrate therapy hypotension develops in 55.5% of cases, and in 72.3% without the therapy (p < 0.05). For the means of prevention of cardiovascular complications during the surgical treatment it is appropriate to keep the therapy with nitrates, though vasodilatives should be canceled 12 hours before the surgery.

[Diagnosis and risk assessment of perioperative cardiovascular complications in geriatric patients in oncological surgery]

Cardiovascular events (CVE) developing at the stages of surgical treatment in 449 geriatric (aged 72 +/- 5.8 years) cancer patients with concomitant cardiovascular diseases (CVD) were quantitatively and qualitatively analyzed. Statistical analysis was used to compare and establish a discrepancy between the results of a predictable risk by the standard scale of the international perioperative CV risk index (ICVRI) and the actually developed complications. The logistic regression method was employed to analyze the risk factors included into the ICVRI scale. The risk factors that were best in predicting the development of CVE were determined. A mathematical formula was derived to estimate the adjusted prognosis of an individual cardiovascular risk. Based on their perioperative CV risk classification, the authors constructed an algorithm of a diagnostic search and surgical preparation tactics in seriously ill cancer patients with concomitant CVD. The algorithm has been put into the routine practice of the P. A. Herzen Moscow Research Institute of Oncology, which makes it possible to improve the results of surgical treatment in geriatric patients and to expand its indications. Examples of clinically applying the algorithm are given.

[Choice of components and a method of anesthesia in geriatric cancer patients with high cardiovascular risk]

Investigations were made at surgical treatment stages in 102 cancer patients (mean age 72 +/- 5.8 years) at high cardiovascular risk, who received continuous therapy that reduced heart rate and blood pressure, in order to compensate for the course of coronary heart disease and arterial hypertension. The time course of changes in the major circulatory and metabolic parameters was analyzed in patients during operations on the abdomen and small pelvis while using three different multimodal anesthetic techniques (general intravenous anesthesia-based diazepam, propofol, fentanyl, ketamine; sevofluorane-based inhalational; combined epidural and intravenous one). The advantages and limitations of the above methods were shown in patients on cardio- and vasotropic therapies. Correcting modes (transesophageal atrial pacing, morning-dose drug withdrawal) for its possible related bradycardiac and hypotensive disorders, which reduce a risk of perioperative cardiovascular complications, are set forth.

[Intra- and postoperative correction of bradycardia by transesophageal electric stimulation]

The authors describe a case of clinical use of transesophageal pacing to correct drug-induced bradycardia during anesthesia, surgery, and in the early postoperative period in a geriatric patient with severe cardiovascular comorbidity who has been long receiving a beta-adrenoblocker. They show it possible to employ the procedure long in the therapy of bradyarrhythmias resistant to the cholinolytic atropine.

[General intravenous anesthesia with spontaneous respiration for noncavitary interventions in cancer]

Two new variants of total intravenous anesthesia with spontaneous respiration were used in 307 female patients subjected to noncavitary interventions for cancer and gynecological cancer. The patients were divided into 2 groups: 1) total anesthesia with midasolam, fentanyl, and calipsol and 2) the same + propofol. Preventive analgesia by preoperative injections of peripheral analgesics was carried out in both groups. Both methods proved to be effective, ensuring good protection from traumatic noncavitary oncological operations. Balanced anesthesia with two hypnotics midasolam and propofol should be preferred, as they mutually potentiate their effects and therefore can be used in the minimum doses, thus preventing the probable side effects, minimizing the use of central analgesics, and ruling out the probability of respiration depression.